[Federal Register Volume 59, Number 197 (Thursday, October 13, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-25372]


[[Page Unknown]]

[Federal Register: October 13, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
 

Statement of Organization, Functions, and Delegations of 
Authority

    Part F of the Statement of Organization, Functions, and Delegations 
of Authority for the Department of Health and Human Services, Health 
Care Financing Administration (HCFA), (Federal Register, Vol. 59, No. 
60, pp. 14634-14637, dated Tuesday, March 29, 1994) is amended to 
reflect changes in the structure of the Office of Managed Care (OMC). 
The OMC-level functional statement has been republished because of a 
change in administrative codes.
    The specific amendments to Part F are as follows:
     Section F.10.A.6. (Organization) is amended to read as 
follows:

6. Office of Managed Care
    a. Program Support Team
    b. Medicaid Managed Care Team
    c. Data Development and Support Team
    d. Beneficiary Access and Education Team
    e. Program Policy and Improvement Team
    f. Medicare Payment and Audit Team
    g. Operations and Oversight Team
    (1) Operations A Team
    (2) Operations B Team
    (3) Operations C Team

     Section F.20.A.6. (Functions) is amended by deleting the 
statement and substructure in their entirety and replacing them with 
the new functional statements. The new functional statements read as 
follows:

6. Office of Managed Care (FAD)

     Provides national direction and executive leadership for 
managed health care operations, including Health Maintenance 
Organizations (HMOs), Prepaid Health Plans (PHPs), Primary Care Case 
Management programs, Competitive Medical Plans (CMPs), and other 
Capitated Health organizations.
     Serves as the departmental focal point in the areas of 
managed health care plan qualification, including quality assurance, 
ongoing regulation, State and employer compliance efforts, Medicare and 
Medicaid HMO, Medicare CMP contracting and Medicaid freedom of choice 
waivers.
     Develops national managed care policies and objectives for 
the development, qualification, and ongoing compliance of HMOs and 
CMPs.
     Plans, coordinates, and directs the development and 
preparation of related legislative proposals, regulatory proposals, and 
policy documents.
     Formulates, evaluates, and prepares policies, 
specifications for regulations, instructions, preprints, and procedures 
related to managed health care.
     Makes recommendations for legislative changes to improve 
managed health care program policy.

a. Program Support Team (FAD-1)

     Develops, coordinates, and implements the Office of 
Managed Care (OMC) staff utilization programs including: employee 
development and training, employee performance, personnel 
administration, recruitment, selection, placement, and position 
control.
     Develops, coordinates, and implements OMC's internal 
financial management program, including formulation, justification, and 
execution of the OMC budget and coordination of OMC contracts and 
cooperative agreement expenditures.
     Processes and implements all OMC program and 
administrative delegations of authority and serves as the focal point 
for all delegations of authority issues concerning OMC.
     Coordinates OMC involvement in outside audit activity 
(e.g. Office of Inspector General, the General Accounting Office).
     Coordinates and tracks the Freedom of Information Act 
requests for OMC.
     Coordinates the controlled correspondence, assignments, 
congressional, and public inquires related to OMC; coordinates 
preparation of replies for the signature of the Secretary of the 
Department of Health and Human Services, the Health Care Administration 
(HCFA) Administrator, OMC Director, and other senior officials.
     Serves as liaison or provides OMC with support services 
such as supply; property management; work space; equipment utilization; 
purchase of computers, hardware, software, and supplies; and printing. 
Orders manual issuances, forms and records.
     Directs, coordinates and tracks strategic and work 
planning efforts for OMC.
     Serves as Project Officer for subject related contracts 
(e.g. consultant, training, evaluation, and program monitoring).
     Develops, modifies, and implements procedures for the 
ongoing maintenance of official files for OMC including: serving as the 
control point for the receipt and initial processing of HMOs 
applications and financial, enforcement, and related documents for 
appropriate dissemination. Maintains the OMC library which serves as 
the primary focal point for distribution of information for the 
industry, the public and OMC staff.
     Provides support to OMC's Program Policy and Improvement 
component (e.g. assistance with regulation and manual clearance).

b. Medicaid Managed Care Team (FAD1)

     Federal focal point for all Medicaid managed care 
activities including operations, policy, and technical assistance.
     Provides oversight of, and assistance to, State Medicaid 
agencies on all Medicaid managed care issues, including managed care 
entity contracting activities. Provides technical assistance to State 
regulators and enforces Federal requirements.
     Evaluates and makes recommendations on the access, 
quality, and cost effectiveness information on State freedom of choice 
waiver requests (including selective provider contracting requests), 
through review of state submittal, independent assessments, and 
regional compliance/validation reviews.
     Evaluates and makes recommendations on managed care 
concerns specified in State health care reform proposals.
     Provides concurrence on managed care issues involving 
Section 1115 waivers.
     Formulates, evaluates, and prepares: policies, 
specifications for regulations, manual instructions, State plan 
preprints, procedures, and legislative proposals related to Medicaid 
managed care.
     Develops guidelines, policies, and procedures for Regional 
Offices (ROs) when reviewing and approving State Medicaid agency 
contracts with managed care entities. Provides training to HCFA ROs for 
contract and waiver reviews.
     Coordinates and tracks Medicaid Freedom of Choice waivers 
and state plan amendments.
     Coordinates Medicaid managed care activities with the 
Medicaid Bureau and other HCFA components.
     Participates in joint projects with other Federal 
agencies, States, and the managed care industry on program specific 
managed care initiatives including: areas related to rate setting; 
marketing; solvency; maternal and child health; Federally Qualified 
Health Centers; and Early and Periodic Screening, Diagnosis, and 
Treatment.
     Supports and participates in Medicaid managed care 
workgroups with state Medicaid agencies, the managed care industry, and 
ROs.
     Provides support to OMC's Program Policy and Improvement 
(e.g. external coordination and communications).

c. Data Development and Support Team (FAD2)

     Manages the HCFA national data systems for Medicare 
beneficiary managed care enrollment and disenrollment. Provides 
enrollment and disenrollment support to HMO which contract with 
independent organizations.
     Develops instructions on procedures for obtaining data on 
Medicare managed care recipient enrollment and disenrollment.
     Develops requirements/specifications for, and works with 
the Bureau of Data Management and Strategy to then develop and maintain 
operational information systems to support current programs (inventory 
collection, analysis, reporting improvements such as: Plan Information 
Control System (PICS), Beneficiary Information Tracking System (BITS), 
Automated Plan Payment System (APPS), Medicaid reports, and monthly 
Data Reporting Requirements (DRR) reports) for the use of HCFA staff. 
Develops and maintains instructions in manuals on PICS, BITS, APPS, the 
Reconsideration Tracking System, and the Group Health Plan System. 
Provides technical assistance to Central Office (CO) and the ROs on 
these systems.
     Manages the Automated Plan Payment System and the National 
Data Reporting Requirements System. Collects and disseminates Medicare 
and Medicaid managed care data to the public (e.g., Medicaid enrollment 
reports).
     Provides special analyses of beneficiary enrollment and 
disenrollment data to monitor managed care membership.
     Provides training to plans and ROs on enrollment, 
disenrollment, and other operational systems processes and 
requirements.
     Develops and implements a long-term strategy for data 
systems improvements including: improved enrollment data, quality 
performance standards tracking, and minimum data sets.
     Develops a policy database information system. Evaluates 
the effectiveness of existing and new managed care data systems and 
implements improvements.
     Works with Federal, State, and the managed care industry 
on formats and methodologies for collecting and reporting encounter 
data and other accountability measures.
     Serves as the Project Officer for contracts to support 
OMC's data needs.
     Produces user-friendly reports of managed care statistics 
and trends.
     Identifies and utilizes software tools for program 
improvement. Serves as trouble shooter and provides assistance to OMC 
components on systems matters.
     Conducts continual monitoring and evaluation of the 
effectiveness of systems security for OMC to assure confidentiality.
     Proposes policy changes in law, regulations, manual 
instructions, and procedures related to Data Development and Support to 
OMC's Program Policy and Improvement component.

d. Beneficiary Access and Education Team (FAD3)

     Serves as the beneficiary advocate regarding access and 
protection in Federal and State contracts with managed care plans and 
the development of Federal and State policies affecting health plans. 
Advises on health plan performance standards to assure beneficiary 
protection.
     Plans, directs, and implements educational efforts to 
improve beneficiary information on health care plans. Develops consumer 
information comparison charts and other educational tools to facilitate 
beneficiary understanding of health care choices.
     Conducts beneficiary focus groups to determine beneficiary 
understanding of managed health care options including: respective 
costs, benefits or quality, and improved consumers education.
     Serves as liaison to the Social Security Administration 
and States to distribute information on managed health plan options to 
beneficiaries.
     Serves as the Federal focal point for providing 
information on beneficiary choice, including presentation of managed 
care options to State Health Insurance Counselling Projects. Develops 
an annual listing of managed care choices available to Medicare 
beneficiaries.
     Plans, conducts, and participates in joint educational 
initiatives on health plan choices with other payers for retirees, 
including Department of Defense, employers, and employer coalitions.
     Develops and implements a strategy of promoting Medicare 
and Medicaid managed care programs to the plan and employer industries, 
in conjunction with the Office of the Associate Administrator for 
Customer Relations and Communications. Develops Federal initiatives to 
promote health education and prevention for beneficiaries in health 
plans.
     Serves as Project Officer for an external contract to 
conduct reconsideration decisions for health plan appeals from 
beneficiaries. Serves as the focal point for policy guidance to the 
contractor. Disseminates data from reconsideration contract to OMC and 
ROs.
     Uses program data, including data from the reconsideration 
contract and other sources, to conduct analyses of beneficiary access 
and utilization of health care services. Identifies problems and 
recommends solutions as appropriate.
     Develops marketing standards for Medicare contracting 
plans and reviews contractor strategies.
     Responds to beneficiary concerns, including Congressional 
and other inquiries. Develops model beneficiary satisfaction surveys 
that can be used by plans to determine beneficiary satisfaction with 
health plan services.
     Proposes policy changes in law, regulations, manual 
instructions, and procedures related to Beneficiary Access and 
Education to OMC's Program Policy and Improvement component.

e. Program Policy and Improvement Team (FAD4)

     Develops managed care policies reflecting OMC's vision, 
Department of Health and Human Services and HCFA initiatives, and 
Congressional mandates. Serves as the focal point for health care 
reform issues within OMC.
     Coordinates policy development within OMC, assuring input 
and recommendations of the affected OMC components. Serves as a policy 
development resource for OMC components. Coordinates policy development 
between OMC and other HCFA, Office of General Counsel, and other policy 
components.
     Serves as the focal point for managed care policy. Plans, 
develops and prepares policy documents including legislative proposals, 
regulatory specifications, policy analysis, instructions, and 
procedures. Develops legislative proposals to improve managed care 
programs. Serves as legislative liaison for OMC components.
     Develops OMC's research and evaluation agenda in 
consultation with HCFA's Office of Research and Demonstrations (ORD).
     Initiates and conducts managed care program policy 
analyses and studies to assess program performance and prepares 
reports.
     Develops program improvement initiatives for OMC (e.g., 
payment reform, future delivery systems, and rural opportunity 
initiatives). Develops initiatives to reach special populations, 
including low income and vulnerable beneficiaries.
     Develops new managed care products (e.g. new contracting 
methods) and programs.
     Coordinates policy issues with other payers.
     Provide leadership and coordinate Medicare SELECT and dual 
eligible issues.
     Reviews HCFA policy documents to determine impact on 
Managed Care components.

f. Medicare Payment and Audit Team (FAD5)

     Establishes and disseminates interim payment rates, 
retroactively adjusts payments, and performs end-of-year settlements 
for all cost-based contracting plans. Ensures timeliness and accuracy 
of all payments to participating plans and develops, reviews, 
validates, and authorizes these payments.
     Recommends payment to plans, checks payment accuracy, and 
resolves payment disputes (including litigation support).
     Develops and implements national payment procedures for 
coordinated health care plans.
     Develops and maintains national instructional manuals on 
coordinated health care payment for coordinated health care plans. 
Provides technical assistance to the plans, ROs, and CO relating to the 
payment process.
     Serves as Project Officer for the outside audit contractor 
who performs the desk review of the HMO and CMP cost reports.
     Reviews budgets and cost reports, manages the financial 
audit process and settlement of final cost reports, ensures payment 
integrity, and authorizes payments to cost-based contractors.
     Determines and approves benefits and premiums on Adjusted 
Community Rate (ACR) reviews for contract renewals. Trains and guides 
OMC staff, contractors and plans in ACR reviews.
     Develops procedures to improve or revise the payment 
methodologies and processes of HMO and CMP Medicare contractors.
     Manages and assures compliance with presumptive cost 
limits for cost-based contractors.
     Ensures that appropriate payment methodologies are 
employed for HCFA Demonstration projects.
     Coordinates OMC data input to the Adjusted Average Per 
Capita Cost process.
     Resolves payment disputes, including litigation support 
for cost-based contractors.
     Proposes changes in law, regulations, manual instructions, 
and procedures related to Medicare Payment and Audit activities to 
OMC's Program Policy and Improvement component.

g. Operations and Oversight Team (FAD6)

     Investigates, evaluates, approves or denies approval of 
applications for new Medicare contracts, Federal Qualification of HMOs, 
and service area expansions of contracts and Federal qualification 
under Section 1301 of the Public Health Service (PHS) Act, Section 1833 
and Section 1876 of the Social Security Act, and related regulations. 
Integrates RO review of elements of applicant operations into approval 
or denial decision on Medicare contract applications.
     Reviews and assures HMO and CMP fiscal soundness and 
solvency during the application process. Monitors financial, fiscal 
solvency provisions, and legal aspects of federally qualified HMO and 
CMP operations. o Coordinates with and provides technical assistance to 
the ROs, state regulators, and professional organizations on review of 
health services delivery, legal, and financial sections of Medicare 
contract and Title XIII applications, as well as other managed care 
requirements.
     Provides oversight of RO performance of monitoring and 
other assigned regional functions. Provides training for RO staff about 
procedures, program requirements and HMO operational issues.
     In consultation with the ROs, establishes HMO/CMP 
contractor performance measures and monitoring and evaluation 
protocols.
     Coordinates with and provides technical assistance to ROs 
and ORD the monitoring of Medicare contracting HMOs and CMPs including 
substantive review of demonstration projects.
     Enforces employer compliance with Section 1310 of the PHS 
Act (the mandatory offering of an HMO alternative to indemnity health 
insurance plans).
     Participates in Medicare contract post-approval activities 
and coordinates all contract renewal/non-renewal, and terminations.
     Evaluates RO recommendations regarding compliance or 
enforcement actions. Implements intermediate sanctions and other 
enforcement authorities and refers cases of Civil Money Penalties to 
the Office of the Inspector General.
     Analyzes Medicare contracting HMO/CMP physician incentives 
and other economic arrangements to enforce appropriate compliance.
     Reviews and approves or denies contracting HMO/CMP 
requests for flexible benefits.
     Serves as Federally Qualified HMOs' primary contact for 
information on activities related to compliance.
     Implements new legislation, regulations or policy 
regarding Medicare contracting with managed care organizations or 
Federal Qualification. Proposes changes in law, regulations, 
instructions, and procedures related to Medicare HMO/CMP and Federally 
Qualified HMO contracts to OMC's Program Policy and Improvement 
component.
     Reviews and approves HMO/CMP mergers, acquisitions, 
changes of ownership, and novation agreements.
     Directs Federal Qualification compliance activities 
inclusive of investigation of complaints, conduct of for cause 
activities, findings of non-compliance and revocation of Federal 
Qualification.
     Monitors loans made under the HMO Loan Program (Section 
1310 of the PHS Act).
     Reviews and approves initial ACR proposals from HMO/CMPs 
applying for a Medicare contract.
(1) Operations A Team (FAD61)
     Investigates, evaluates, approves or denies approval of 
applications for new Medicare contracts, Federal Qualification of HMOs, 
and service area expansions of contracts and Federal qualification 
under Section 1301 of the PHS Act, Section 1833 and Section 1876 of the 
Social Security Act, and related regulations. Integrates RO review of 
elements of applicant operations into approval or denial decision on 
Medicare contract applications.
     Reviews and assures HMO and CMP fiscal soundness and 
solvency during the application process. Monitors financial, fiscal 
solvency provisions, and legal aspects of federally qualified HMO and 
CMP operations.
     Coordinates with and provides technical assistance to the 
ROs, state regulators, and professional organizations on review of 
health services delivery, legal, and financial sections of Medicare 
contract and Title XIII applications, as well as other managed care 
requirements.
     Provides oversight of RO performance of monitoring and 
other assigned regional functions. Provides training for RO staff about 
procedures, program requirements and HMO operational issues.
     In consultation with the ROs, establishes HMO/CMP 
contractor performance measures and monitoring and evaluation 
protocols.
     Coordinates with and provides technical assistance to ROs 
and ORD on the monitoring of Medicare contracting HMOs and CMPs 
including substantive review of demonstration projects.
     Enforces employer compliance with Section 1310 of the PHS 
Act (the mandatory offering of an HMO alternative to indemnity health 
insurance plans).
     Participates in Medicare contract post-approval activities 
and coordinates all contract renewal/non-renewal, and terminations.
     Evaluates RO recommendations regarding compliance or 
enforcement actions. Implements intermediate sanctions and other 
enforcement authorities and refers cases of Civil Money Penalties to 
the Office of the Inspector General.
     Analyzes Medicare contracting HMO/CMP physician incentives 
and other economic arrangements to enforce appropriate compliance.
     Reviews and approves or denies contracting HMO/CMP 
requests for flexible benefits.
     Serves as Federally Qualified HOMs' primary contact for 
information on activities related to compliance.
     Implements new legislation, regulations or policy 
regarding Medicare contracting with managed care organizations or 
Federal Qualification. Proposes changes in law, regulations, 
instructions, and procedures related to Medicare HMO/CMP and Federally 
Qualified HMO contracts to OMC's Program Policy and Improvement 
component.
     Reviews and approves HMO/CMP mergers, acquisitions, 
changes of ownership, and novation agreements.
     Directs Federal Qualification compliance activities 
inclusive of investigation of complaints, conduct of for cause 
activities, findings of noncompliance and revocation of Federal 
Qualification.
     Monitors loans made under the HMO Loan Program (Section 
1310 of the PHS Act).
     Reviews and approves initial ACR proposals from HMO/CMPs 
applying for a Medicare contract.
    (2) Operations B Team (FAD62)
     Investigates, evaluates, approves or denies approval of 
applications for new Medicare contracts, Federal Qualification of HMOs, 
and service area expansions of contracts and Federal qualification 
under Section 1301 of the PHS Act, Section 1833 and Section 1876 of the 
Social Security Act, and related regulations. Integrates RO review of 
elements of applicant operations into approval or denial decision on 
Medicare contract applications.
     Reviews and assures HMO and CMP fiscal soundness and 
solvency during the application process. Monitors financial, fiscal 
solvency provisions, and legal aspects of federally qualified HMO and 
CMP operations.
     Coordinates with and provides technical assistance to the 
ROs, state regulators, and professional organizations on review of 
health services delivery, legal, and financial sections of Medicare 
contract and Title XIII applications, as well as other managed care 
requirements.
     Provides oversight of RO performance of monitoring and 
other assigned regional functions. Provides training for RO staff about 
procedures, program requirements and HMO operational issues.
     In consultation with the ROs, establishes HMO/CMP 
contractor performance measures and monitoring and evaluation 
protocols.
     Coordinates with and provides technical assistance to ROs 
and ORD on the monitoring of Medicare contracting HMOs and CMPs 
including substantive review of demonstration projects.
     Enforces employer compliance with Section 1310 of the PHS 
Act (the mandatory offering of an HMO alternative to indemnity health 
insurance plans).
     Participates in Medicare contract post-approval activities 
and coordinates all contract renewal/non-renewal, and terminations.
     Evaluates RO recommendations regarding compliance or 
enforcement actions. Implements intermediate sanctions and other 
enforcement authorities and refers cases of Civil Money Penalties to 
the Office of the Inspector General.
     Analyzes Medicare contracting HMO/CMP physician incentives 
and other economic arrangements to enforce appropriate compliance.
     Reviews and approves or denies contracting HMO/CMP 
requests for flexible benefits.
     Serves as Federally Qualified HMOs' primary contact for 
information on activities related to compliance.
     Implements new legislation, regulations or policy 
regarding Medicare contracting with managed care organizations or 
Federal Qualification. Proposes changes in law, regulations, 
instructions, and procedures related to Medicare HMO/CMP and Federally 
Qualified HMO contracts to OMC's Program Policy and Improvement 
component.
     Reviews and approves HMO/CMP mergers, acquisitions, 
changes of ownership, and novation agreements.
     Directs Federal Qualification compliance activities 
inclusive of investigation of complaints, conduct of for cause 
activities, findings of non-compliance and revocation of Federal 
Qualification.
     Monitors loans made under the HMO Loan Program (Section 
1310 of the PHS Act).
     Reviews and approves initial ACR proposals from HMO/CMPs 
applying for a Medicare contract.
(3) Operations C Team (FAD63)
     Investigates, evaluates, approves or denies approval of 
applications for new Medicare contracts, Federal Qualification of HMOs, 
and service area expansions of contracts and Federal qualification 
under Section 1301 of the PHS Act, Section 1833 and Section 1876 of the 
Social Security Act, and related regulations. Integrates RO review of 
elements of applicant operations into approval or denial decision on 
Medicare contract applications.
     Reviews and assures HMO and CMP fiscal soundness and 
solvency during the application process. Monitors financial, fiscal 
solvency provisions, and legal aspects of federally qualified HMO and 
CMP operations.
     Coordinates with and provides technical assistance to the 
ROs, state regulators, and professional organizations on review of 
health services delivery, legal, and financial sections of Medicare 
contract and Title XIII applications, as well as other managed care 
requirements.
     Provides oversight of RO performance of monitoring and 
other assigned regional functions. Provides training for RO staff about 
procedures, program requirements and HMO operational issues.
     In consultation with the ROs, establishes HMO/CMP 
contractor performance measures and monitoring and evaluation 
protocols.
     Coordinates with and provides technical assistance to ROs 
and ORD on the monitoring of Medicare contracting HMOs and CMPs 
including substantive review of demonstration projects.
     Enforces employer compliance with Section 1310 of the PHS 
Act (the mandatory offering of an HMO alternative to indemnity health 
insurance plans).
     Participates in Medicare contract post-approval activities 
and coordinates all contract renewal/non-renewal, and terminations.
     Evaluates RO recommendations regarding compliance or 
enforcement actions. Implements intermediate sanctions and other 
enforcement authorities and refers cases of Civil Money Penalties to 
the Office of the Inspector General.
     Analyzes Medicare contracting HMO/CMP physician incentives 
and other economic arrangements to enforce appropriate compliance.
     Reviews and approves or denies contracting HMO/CMP 
requests for flexible benefits.
     Serves as Federally Qualified HMOs' primary contact for 
information on activities related to compliance.
     Implements new legislation, regulations or policy 
regarding Medicare contracting with managed care organizations or 
Federal Qualification. Proposes changes in law, regulations, 
instructions, and procedures related to Medicare HMO/CMP and Federally 
Qualified HMO contracts to OMC's Program Policy and Improvement 
component.
     Reviews and approves HMO/CMP mergers, acquisitions, 
changes of ownership, and novation agreements.
     Directs Federal Qualification compliance activities 
inclusive of investigation of complaints, conduct of for cause 
activities, findings of non-compliance and revocation of Federal 
Qualification.
     Monitors loans made under the HMO Loan Program (Section 
1310 of the PHS Act).
     Reviews and approves initial ACR proposals from HMO/CMPs 
applying for a Medicare contract.

    Dated: September 30, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 94-25372 Filed 10-12-94; 8:45 am]
BILLING CODE 4120-01-P